Treatment algorithms

Table 1: Algorithm for treatment with TNF inhibitors of patients with treatment failure.

Measurable drug level
/ Negative for NAbs

Drug level below detection limit / Negative for NAbs

Drug level below detection limit / Positive for NAbs

â€¢ Compliance issues? Does the patient take the medication as directed?
â€¢ Does the patient need a higher drug dose or more frequent dosing interval?
â€¢ The patientâ€™s disease is not driven by TNF levels. Change type of treatment.
â€¢ Was the sample collected at Cmin? NAbs are measured with optimal result at Cmin.

â€¢ Compliance issues? Does the patient take the medication as directed?
â€¢ Does the patient need a higher drug dose or more frequent dosing interval?
â€¢ Non-neutralizing ADA can both limit the bioavailability (with local administration of the drug) and increase the elimination of drug in circulation.

â€¢ Change TNF inhibitor because NAbs influence the activity of the currently used TNF inhibitor.

Inspiration from Bendtzen 2011, 2013, GarcÃªs 2013, Vincent 2013.

Table 2: Algorithm for treatment with TNF inhibitors of patients that respond to treatment.

Measurable drug level /Negative for NAbs

Drug level below the detection limit / Positive for NAbs

â€¢ Everything is OK. Follow up with new tests at regular intervals.
â€¢ Should the drug dosage be adjusted?
â€¢ Is the patient is in remission and can treatment be discontinue?

â€¢ The patient is in remission and can formally discontinue treatment.